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Background: Glucocorticoid (GC) use is well established in the treatment of rheumatics diseases, particularly rheumatoid arthritis (RA). The use of low dose GC has been endorsed by EULAR recommendations for the management of rheumatic and musculoskeletal diseases even if in the context of SARS-CoV-2, but long-term use is generally discouraged. Objectives: To estimate the prevalence of glucocorticosteroids induced osteoporosis (GIOP) on bone mineral density (BMD) in African adult patients with infammatory rheumatic diseases. Methods: For this systematic review and meta-analysis, PubMed, Google Scholar, Scopus and African index medicus were systematically searched up to December 2020 without language restrictions. We included studies as follows: population-based or hospital-based study, study with sufficient information to estimate the prevalence of GIOP and osteoporotic fractures in African patients with rheumatic disease. Searches were limited to peer-reviewed full text articles. A standardized data extraction form was used to collect information from eligible studies. A random-effects meta-analysis was conducted to obtain the pooled prevalence of GIOP in these studies. The meta-analysis was strati-fed by geographical region. The study is registered with PROSPERO, number CRD42021256252. Results: Our search identifed 8571 studies, of which 8 studies were included in the systematic review from only four African countries and 7 studies in the meta-analysis. The pooled prevalence of osteoporotic fractures in our study was 47.7% (95% CI 32.9-62.8) with 52.2% (95% CI 36.5-67.6) in North Africa and 15.4% (95% 1.9-45.4%) in South Africa (SA). There was no evidence of publication bias, although heterogeneity was high (p=0.018). There was no data from sub-Saharan Africa apart from the two studies from SA. Conclusion: The overall prevalence of GIOP in African adult patients with infam-matory rheumatic diseases was high at 47.7% (95% CI 32.9-62.8). Meta-analysis calculation revealed patient geographic origin as possible confounding factors of the proportion outcomes and further studies are required.
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Background: The Covid-19 pandemic has been raging for more than a year in a pandemic mode. Since then, many questions have been raised regarding the management of patients with rheumatic diseases (RD). In this context, the maintenance therapy of conventional, biologic and targeted synthetic disease-modifying antirheumatic drugs (Cs DMARDs, bDMARDs and tsDMARDs respectively) during the Covid-19 infection remains a subject of debate given their immuno-suppressive effects as well as their potential generation of lung fbrosis. While the EULAR 2020 guidelines emphasize that discontinuation or maintenance should be discussed on a case-by-case basis, the ACR guidelines advocate discontinuation of all therapies except for the anti-interleukin-6 [1,2]. Objectives: The objective of our work was to report our real-life experience of therapeutic maintenance during the covid-19 pandemic. Methods: We conducted a cross-sectional study of patients with RD: rheumatoid arthritis (RA) and spondyloarthritis (SpA) recruited from the rheumatology department of the Kassab Institute of Orthopedics. All the patients were asked to complete a questionnaire about their disease management in the era of the Covid-19. The questionnaire included sociodemographic data, treatment modalities, as well as data related to the infection with the Covid-19 (severe forms defned by the need for oxygen therapy or hospitalization), and changes in treatment during the infection. Results: The study included 102 patients with RA (65.3%) and SpA (34.7%). The mean age was 52.4 ± 13 [19-77] years. There was a female predominance with a sex ratio of 0.4. The mean duration of the disease was 7. 8 ± 5 years [1-35]. Fifteen percent of patients were on corticosteroids with a mean dose of 6.7±4.5 mg/L [2-20] of prednisone equivalent. A CsDMARD was prescribed alone in 36.3% of cases and combined with a biologic in 18% of cases. A Covid-19 infection was occurred at least once in 25.5% of cases, of which 19.2% had a severe form (hospitalization (15.4%), oxygen therapy (19.2%)). No deaths were observed. The treatments received during the covid-19 infection were: corticosteroids (n=5), heparin therapy (n=6) and antibiotic therapy (n=10). No patient tapered treatment dosage of DMARDs but discontinuation was reported by 4 patients with a mean time between discontinuation and resumption of 2.1 ± 2 months [0.5-5 months]. The cessation of the treatment was dictated by the treating physician in 2 cases and involved csDMARD in 3 cases (Methotrexate (n=2), Lefunomide (n=1)) and biologics in only one patient. There were no cases of clinical pulmonary worsening upon resumption of the treatments. We found no statistically signifcant association between severe forms of the infection and the type of RD (p=0.925), as well as the presence of comorbidities (p=0.825). Similarly, the presence of severe forms was not associated with the use of long-term NSAIDs (p=0.29), corticosteroids (p=0.85), or biological treatment (p=0.7). However, maintenance therapy was signifcantly associated with a lower risk of severe forms (p=0.013). Conclusion: Our work showed that the maintenance of conventional treatment during Covid-19 infection was associated with a lower risk of severe forms. Our results, along with those of other studies in the literature, support the maintenance of antirheumatic treatments.
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Background: The advent of COVID-19 has allowed a rapid expansion of tele-medicine (TM) and its implementation in various specialties. Despite this extensive use of TM, its role in rheumatology is conficting and much remains unknown about TM's acceptability and efficiency in rheumatology [1]. Objectives: Our study aimed to evaluate rheumatologists' and patients' willingness for TM and factors helping to adopt this alternative. Methods: We conducted a cross-sectional study including patients attending our rheumatology department as well as rheumatologists. Patients were contacted by phone and rheumatologists were invited to answer a questionnaire via Google Form. We evaluated their points of view and suitability for TM by inquiring about their experience with tele-rheumatology, information technology supports, personal barriers to telemedicine, and reasons for adopting this alternative. Moreover, additional questions probed the clinician's perception of the appropriate clinical context for TM application as well as the corresponding legislation. Results: Overall, 135 responses were collected including 60 rheumatolo-gists and 75 patients. The distribution of diagnosis was as follows: rheumatoid arthritis (RA) (n=15), spondyloarthritis (SpA) (n=20), juvenile idiopathic arthritis (n=23), and osteoarthritis (n=17). Of the rheumatologists, 76.2 % were aged between 30 and 50 years old, 79.3% reported working at an academic center, and the majority were physician-level practitioners (71.2%), working for more than 5 years (61%). Afforded electronic devices were as follows: laptop (87.9%), smartphone (70.7%), afforded headset microphone (24.1%), camera (29.3%) for doctors. Forty-six percent of the rheumatologists estimate that they have a good internet connexion, 62.7% had an appropriate place for teleconsultation. Nearly, 40.7% of the rheumatologists were familiar with the concept of TM but only 39% reported experience with TM. Willingness to accept this model of care for rheumatologists and patients was found in 78% and 37.3% respectively. According to the doctors, the benefts of TM encompassed tele-training (61.7%), remote medical monitoring (61.7%) especially during the COVID-19 (70.2%), benefts for patients (74.5%), reduced inequalities in access to healthcare (46.8%), and improved quality of care (29.8%). The main barriers to TM were the lack of clear legislation (47.8%) and fnancial compensation (17.4%). Clinicians and patients identifed common barriers to effective tele-rheumatology as the inability to perform a physical exam (91.3% vs 33.3%), the fear of trivializing the disease (34.8% vs 36%), and the lack of resources and infrastructures (43.5% vs 29.3%). The majority of the doctors (86.2%) expressed their willingness to attend training workshops. Reported areas to apply TM according to the doctors were mainly osteoarthritis (76.3%) and rheumatic diseases (64.4%), but also pediatric rheumatology (28.8%) and undiagnosed new patients (3.4%). Regarding legislation, most of practitioners estimated that it should be selective with specifc authorizations (42.4%) or relaxed with the possibility of derogation (32.2%). Twenty-two percent of them reported that legislation should be strict with the possibility of sanctions, whereas a minority (3.4%) opted for a free practice without regulation at all. Factors associated with adherence to TM were age<40 years (p=0.036) for doctors and familiarity with the concept (p=0.006) and electronic devices afforded (p=0.000) for the patients. Conclusion: Findings from this study showed the reluctance of the patients to adhere to TM compared to doctors. Concerns and risks may lessen for both sides, once remote consultations are applied. Nevertheless, patient education is required for the success of TM application.
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Background: The COVID-19 pandemic is a major concern for the management of patients with rheumatic diseases (RD). Indeed, an increasing risk of coronavirus infection has been demonstrated in these patients, explained on the one hand by the chronic infammation and on the other hand by the immu-no-modulating treatments used [1]. In this context, vaccination represent an efficient mean to prevent infections and should be included in the management of these patients. Objectives: The objective of our study was to determine the peculiarity of vaccination against SARS-COV2 in patients with RD treated with biologic therapies. Methods: We conducted a cross-sectional study during August 2021, including patients with RD: rheumatoid arthritis (RA) and spondyloarthritis (SpA). Sociodemographic data as well as disease characteristics were recorded. Patients were asked to answer a self-questionnaire about SARS-COV2 vaccination: modalities, time between doses, type of vaccine, adverse events, and time to biologic injection. We compared these results between the two groups: group 1 patients on biologics and patients on conventional disease-modifying antirheumatic drugs (DMARDs). A significance level was set for p<0.05. Results: The study included 102 patients with RD: RA (65.3%) and SpA (34.7%). The mean age was 52.4 ± 13 years [19-77]. There was a female predominance (71 women and 31 men) with a gender ratio of 0.4. The mean duration of disease progression was 7. 8 ± 5 years [1-35]. Fifteen percent of patients were on corticosteroids with a mean dose of 6.7 mg [2-20] of prednisone equivalent. A CsDMARD was prescribed alone in 36.3% of cases and combined with a biologic in 18% of cases. SARS-COV2 infection was found in 27.3% of cases, of which 19% had a severe form. Sixty percent of patients received the SARS-COV2 vaccine, and 25% of them received only the frst dose. The mean time between the two injections was 27 ± 7. 6 days [23-67 days]. The most common type of vaccine was Pfzer (54.4%), Moderna (5.5%), followed by AstraZeneca (20%), Sinovac (16.4%), Johnson (1.8%) and Sputnik (1.8%). Three patients deferred their biotherapy injection by one week. Only one patient discontinued methotrexate therapy for one month. Sixteen patients reported adverse events such as injection site pain (62.5%), disease fare (12.5%) and fatigue and fever (25%). Patients receiving biologics were not at greater risk of SARS-COV2 infection (p=0.076) or hospitalization (p=0.131) compared to patients receiving conventional therapy. Similarly, patients on conventional therapy did not report more adverse events (p=0.678). The vaccination rate was signifcantly higher in patients on biologics compared to patients on CsDMARD: 72% versus 43%, p=0.004. Conclusion: Our work demonstrated that patients treated with biologics adhered to vaccination and did not have more SARS-COV2 infections or adverse events compared to patients on conventional treatment.
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Introduction Avec l’avènement de la pandémie de COVID-19, le système de santé a été confronté à des difficultés pour fournir des soins appropriés aux patients suivis au long cours pour des pathologies autres que le COVID-19. Ces derniers, du fait de la chronicité de leurs maladies, nécessitent un suivi régulier et rapproché [1]. Quoique la télémédecine n’est pas encore officiellement mise en œuvre en Tunisie, cette alternative peut avoir le potentiel d’améliorer l’accès aux soins en plus de réduire les dépenses de santé. L’objectif de notre étude était d’évaluer la perception de la télémédecine par les patients suivis en rhumatologie et d’étudier les facteurs favorisant l’adoption de cette alternative à l’ère du COVID-19. Patients et méthodes Nous avons mené une enquête transversale structurée par téléphone auprès des patients suivis au service de rhumatologie de l’institut Kassab d’orthopédie, pour un rhumatisme inflammatoire chronique ou pour une pathologie dégénérative. Les données sociodémographiques et les caractéristiques de leur maladie ont été recueillies. Nous avons évalué leur point de vue et leur aptitude à la télémédecine. Résultats L’étude a inclus 75 patients. Il y avait une prédominance féminine avec un sex-ratio de 0,4. La répartition des pathologies rhumatismales était comme suit: polyarthrite rhumatoïde (PR) (20 %), spondyloarthrite (SpA) (26,6 %), arthrite juvénile idiopathique (30,7 %), et pathologie dégénérative (22,7 %). La durée d’évolution de la maladie était en moyenne de 9,8±7,5 [1–29] ans. Près de la moitié des patients (46,7 %) avaient un revenu mensuel inférieur à 500 dinars et 44 % d’entre eux avaient un revenu mensuel entre 500 et 1000 dinars (151 et 303 euros). La durée moyenne du trajet pour se rendre à l’hôpital était de moins de 2 heures dans 61,3 % des cas, entre 2 et 5 heures dans 28 % des cas et plus de 5heures dans 10,7 % des cas. Les appareils électroniques disponibles étaient les suivants: smartphone (18,7 %), internet (16 %), téléphone portable simple (24 %), et l’association des trois (41,3 %). Seuls 14 patients connaissaient le concept de télémédecine et 37,3 % d’entre eux accepteraient ce modèle de soins. Le moyen de télécommunication le plus apte à être adopté selon les patients était les appels vidéo (64 %) comparé aux appels téléphoniques (36 %). Les principales raisons de préférer la télémédecine étaient comme suit: éviter les hôpitaux pendant la pandémie (28 %), faire des économies (25,3 %), gagner du temps (26,7 %) et éviter l’absentéisme (14,7 %). Les principales raisons de préférer la consultation en direct étaient la crainte d’une éventuelle discordance entre l’évaluation physique et l’évaluation à distance (33,3 %), la crainte de la banalisation de la maladie (36 %), les inquiétudes quant à maîtrise de la technologie (21,3 %) et enfin, la crainte de perdre la connectivité (29,3 %). Il n’y avait pas d’association entre la préférence pour la télémédecine et le motif de consultation (p=0,87), un revenu plus élevé (p=0,84), la durée du trajet vers l’hôpital (p=0,07), la profession (p=0,54), ainsi que des antécédents familiaux de COVID-19 (p=0,54). Les patients au courant du concept de télémédecine et disposant de ressources électronique adhéraient plus à la télémédecine (p=0,006, p=0,000 respectivement). Conclusion Contrairement aux données de la littérature, notre étude a montré la faible prévalence des patients prêts à accepter la télémédecine comme modèle de soins. En effet, en Tunisie, le concept de télétravail en général n’était pas d’usage courant avant la pandémie, d’où la nécessité de sensibiliser les patients d’avantage afin de promouvoir cette alternative.
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Background: Concerns over the safety of non-steroidal anti-inflammatory drugs (NSAIDs) use during severe acute respiratory syndrome associated with coronavirus 19 disease (covid-19) have raised. NSAIDs are one of the most commonly prescribed and used pain medications for acute and chronic rheumatic diseases such as spondyloarthritis (SpA) and osteoarthritis. Objectives: This study aimed to assess the impact of covid-19 pandemic on NSAIDs prescription. Methods: A cross-sectional web survey was disseminated to all Tunisian rheumatologists through a mailing system and social media. The French version was accessible on Google form. It included close-ended questions about the prescription of NSAIDs during covid-19 pandemic. Participation was anonymous. Data collection and analysis was performed between January the first and January 30, 2021. Results: Among one hundred and thirty Tunisian rheumatologists, thirty responded to the online questionnaire. Ninety percent of participants were women. The mean age of rheumatologists was 34 years [25-57]. The duration of practice was inferior to 5 years in 59.3%, between 5 and 10 years in 18.5%, and superior to 10 years in 22.2% of cases. Sixty-three percent of rheumatologists reported that their activity decreased during covid-19 pandemic. NSAIDs prescription was avoided as much as possible in 40.7% of cases. The participants indicated NSAIDs less frequently in 33.3% of cases, and as much as before the pandemic in one-quarter of cases. Rheumatologists believed that NSAIDs worsen the respiratory symptoms (67%), delay recovery (55%), and increase mortality (48%), hospitalization in intensive care (44%), and infectious complications (33%). The participants suggested that the most incriminated NSAIDs were: Ibuprofen (7.4%), indomethacin (7.4%), celecoxib (7.4%), and diclofenac (3.4%). The majority of rheumatologists (74%) believed that all NSAIDs had a similar risk. For patients with osteoarthritis, rheumatologists replaced NSAIDs with paracetamol and corticoids in 78% and 11% of cases, respectively. If mandatory, reducing NSAIDs doses or duration was an option in 22% and 74% of cases. For patients with SpA, half of rheumatologists did not change the treatment. However, the participants limited the use of NSAIDs or discontinued the treatment in patients with comorbidities. More than 60% of rheumatologists didn't know the effect of NSAIDs in the post-covid-19 syndrome. Conclusion: Covid-19 pandemic has affected rheumatologists' practice. Rheumatic disease management during this pandemic may be challenging. More evidence is mandatory to standardize treatment prescription, especially with NSAIDs.
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Introduction Durant la pandémie COVID-19, une réorganisation des secteurs professionnels avait été proclamée. Les répercussions sociales observées, notamment chez les patients suivis en rhumatologie, avaient entravé leur qualité de vie et la bonne évolution de leur maladie. L’objectif était d’évaluer l’impact des changements professionnels sur le statut socioéconomique et l’état de santé des patients en milieu rhumatologique. Patients et méthodes Étude monocentrique transversale, menée sur une période de deux mois, à la levée du confinement généralisé. Nous avons utilisé un questionnaire intéressant 92 patients vus en hospitalisation traditionnelle, de jour et en consultation externe, ou interrogés par un entretien téléphonique. Nous avons évalué : les caractéristiques sociodémographiques, le niveau d’études, le statut professionnel, la nature de la pathologie rhumatismale, les paramètres associées à la profession durant le confinement. Résultats La moyenne d’âge était de 50,8 ans [16–78]. Les pathologies rencontrées étaient la polyarthrite rhumatoïde (34,8 %), les spondyloarthrites (22,8 %), l’arthrite juvénile idiopathique (2,1 %) et autres rhumatismes inclassables (3,2 %). Les pathologies arthrosiques et osseuses étaient présentes au second plan (36,9 %). Les patients étaient mariés (66 %), célibataires (19 %), veufs (13 %) et divorcés (2 %). Vingt-six pour cent des patients étaient analphabètes et seul le tiers avaient une activité professionnelle. La majorité des patients étaient issus d’un milieu urbain (77 %). La nature du travail se répartissait comme suit : 33 % étaient des journaliers, 26 % des commerçants, 18 % étaient respectivement des cadres administratifs et sanitaires, 3,5 % étaient des auxiliaires de ménage. La plupart des patients ont vécu une réorganisation du rythme de travail. Seuls 3 % avaient bénéficié d’un télétravail et 89 % ont été en arrêt d’activité professionnelle. Vingt pour cent des patients avaient perdu leur source de revenus. Ces changements avaient contribué à des difficultés financières importantes aux patients (41 %) ainsi qu’à leurs proches (44 %). Toutefois, la poursuite de l’activité professionnelle durant le confinement (8 %) était associée à la dépression (p=0,011), aux trous de mémoire (p=0,011) et au sentiment de solitude (p=0,011). Conclusion Les changements professionnels vécus au cours de la crise COVID-19 avaient causé un impact réel sur la vie des patients. Ceci avait augmenté leur stress connu et pouvant entraver davantage l’évolution de leur maladie.
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Introduction Au cours de la pandémie COVID-19, les soins en milieu rhumatologique ont été fortement perturbés. Une réorganisation a été nécessaire avec un recours massif à la téléconsultation ainsi qu’aux espacements et report des rendez-vous. On en a découvert les avantages que sont la rapidité de la prise en charge mais on en a aussi connu quelques limites dont l’impossibilité de bien évaluer certaines pathologies rhumatismales. L’objectif de notre étude était d’identifier l’effet de la réorganisation des structures sanitaires sur l’observance au traitement et son impact sur la maladie. Patients et méthodes Étude monocentrique transversale, menée à la levée du confinement généralisé, au moyen d’un questionnaire téléphonique ou intéressant des patients vus en hospitalisation traditionnelle, de jour, ou en consultation externe. Les éléments suivants ont été évalués : la nature de la pathologie rhumatismale, les comorbidités, les traitements reçus, l’adhésion au traitement et l’évolution de la maladie. Résultats Nous avons recensé 92 patients (dont 65 femmes). La moyenne d’âge était de 50,8 ans [16–78]. Les patients étaient suivis pour un rhumatisme inflammatoire chronique dans 63 % des cas, à type de polyarthrite rhumatoïde (35 %), spondyloarthrites (23 %), arthrite juvénile idiopathique (2 %) et rhumatismes inclassables (3 %). Les pathologies arthrosiques étaient présentes chez 32 % des patients. Cinq pour cent des patients étaient suivis pour une autre pathologie ostéoarticulaire. Cinquante-trois pour cent des patients étaient sous csDMARDS et 57 % sous bDMARDS. Les corticostéroïdes (CS) et les anti-inflammatoires non stéroïdiens (AINS) étaient prescrits chez respectivement 12 % et 13 % des patients. Trente-sept patients (40 %) avaient signalé une difficulté à se rendre à l’hôpital à la date de leurs rendez-vous. Trente-six pour cent des patients ont eu recours à la téléconsultation. Le tiers des patients avait reçu une éducation thérapeutique par leur rhumatologue traitant, portant sur l’importance de l’observance aux traitements avec un changement à leur liste ou à leur dose de médicaments. Concernant le maintien thérapeutique, 54 % des patients sous bDMARDS avaient déclaré avoir pris leur traitement régulièrement. Le pourcentage d’adhésion aux csDMARDS a été de 61 %. La prise des CS et des AINS a été régulière dans respectivement 64 et 42 % des cas. Parmi les patients qui étaient incapables d’obtenir leurs médicaments (41 %), les causes ont été intriquées et réparties comme suit : dans 91 % des cas les patients n’ont pas pu se rendre à la structure de soins. Un problème d’approvisionnement par la caisse de remboursement a été retrouvé dans 62 % des cas. Le médicament était indisponible dans 75 % des cas. Un manque de moyens financiers avait empêché l’obtention du médicament dans 33 % des cas. Cette désorganisation avait comme conséquence le déclenchement d’une poussée de la maladie notée chez 57,4 % des patients, notamment ceux atteints de RIC, ainsi qu’une décompensation de tares (10 %). Conclusion La réorganisation des soins en rhumatologie en période de confinement a été responsable d’un déséquilibre de prise en charge. Ainsi, une stratégie d’éducation thérapeutique régulière est nécessaire afin de maintenir une adhésion durable aux traitements.